CORPORATE INDUCTION. What does Governance mean in Tameside Hospital NHS Trust?

Transcription

1 CORPORATE INDUCTION What does Governance mean in Tameside Hospital NHS Trust?

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3 What is Governance? Systems and processes by which Trusts lead, direct and control their functions in order to achieve organisation objectives, safety and quality services and through which they relate to patients, the wider community and partner organisations Department of Health definition Professor M Deighan

4 How does Governance support the Trust s objectives? Safety / Quality Clinical and Cost effectiveness Patient Focus / Experience Accessible and Responsive Care Care Environment Public Health

5 What should our patient s expect? (and what do the regulators look for?) Safe Care Effective Care Caring Staff Responsive services Well led Services and organisation

6 So how do we make a patient journey safer/safe? Training and Learning Communication Policy Risk/Hazard awareness Risk assessment and management Incident Reporting (Incident form or e-form via TIS) Learning from what happened before (Fair blame culture)

7 Risk Management and Health and Safety at work Policy: a copy of the most recent version of the Trust s Risk Management Strategy. Policy and Guidance is available on the Trust intranet. Every employee has a duty of care to abide by Trust Policies and procedures. When you notice a risk, whether clinical or non-clinical, you must report it using an incident report form.

8 Incident Reporting Incident Reporting and Investigation Policy - copy available on the TIS (intranet) All incidents and near misses MUST be reported using the on line reporting form. The Incident reporting form is accessed on TIS (Click on Red Button on TIS lefthand side of the homepage)

9 Incident Reporting The Trust has a fair blame incident reporting policy and the emphasis is on learning lessons from incidents, rather than any disciplinary action. For advice on any matter relating to Risks or an Incident, please contact the Quality and Governance unit on or ext. 6668

10 Managing Complaints and Concerns What can you do? Patients, relatives and carers should be able to bring enquiries and concerns to the attention of any staff member. Listen to what they have to say Address the issues at the earliest opportunity if you can, or Refer them to a more senior manager or person in charge A written complaint should be the last option!

11 Managing Complaints and Concerns (PALS and Complaints team) Direct concerns to manage the issue in real time or provide an answer quickly Written complaints all receive a Senior clinical/managerial review with appropriate follow-up and acknowledgement Investigating officer assigned to manage investigation and draft response Responses signed by the Chief Executive or nominated officer

12 What happens if something goes wrong or not according to plan? Review Investigation Being open Complaints Claims Inquests Shared learning

13 Information Governance Safe Communication and Management of data and information Safe ing of information using:- NHS mail or Trust secure [secur ] Safe faxing details available in the Safehaven policy via TIS Safe use of computers using your own login and password, log off and ensure screens not left attended The Trust main patient and staff information systems use SmartCard access You need to be trained before being allowed access Safe use of social media sites Disposal of confidential waste The Trusts (SIRO) Senior Information Risk Officer is the Director of Performance and Information

14 Information Governance Person Identifiable Information - Safe Communication and Management Legal obligation to keep person identifiable information confidential and applies to information in all media for patient and staff Share personal information needed for clinical care only In case of request for patient information for other purposes, particularly from Police, consult a senior colleague or the Caldicott Guardian (Medical Director) Be aware of the information, other people may overhear When copying records, always ensure the originals are removed from the copier Use the NHS number on all documentation

15 Health Records The Health Records Policy provides guidance on the standards and expectations of the Trust in relation to the management of health records (available at on TIS) The standards in relation to clinical record keeping are provided in the Clinical Record Keeping Policy(available at on TIS) Complete Accurate Relevant Accessible Timely The NHS number should be used as the unique personal identifier for all patients

16 Who to contact? Name Role Phone: (Ext) Peter Weller Director of Quality and Governance (6223) John Fletcher Head of Assurance and Governance (4278) Stuart Bates Head of Openness and Candour (6343) Naz Khadim Head of Adult Safeguarding & Prevent lead (5202) Viv Buckett Head of Clinical Effectiveness and Audit (6671) Alexia Charnley PALS and Complaints coordinator (4031) Jason Gravestock Divisional Governance lead Medicine (4287) Richard Convey Divisional Governance lead Surgery & Anaesthetics (5945) Sharon Camkin Divisional Governance lead Women's and Childrens (6174) Dave Hulme Divisional Governance lead Community (4474) Amanda Dooley Health and Safety and Risk officer (5343) Sally Sutcliffe Clinical Effectiveness - Patient Safety Officer (4277) Maria Neild Senior Nurse: Clinical Effectiveness Mortality reviews (4270) Vacant Safeguarding /DOLS Practitioner (4327) Amanda Fearon VTE Nurse (4270) Lorraine Wood Sepsis and AKI - Patient Safety Officer (4275) Ansuya Patel Information Governance/FOI (6936)

17 To conclude Your role in Governance and Risk Management is important Your actions are important You are important GOVERNANCE IS EVERYBODY S BUSINESS